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ANNEX 6. LIST OF PROCEDURE CASE RATES FOR PRIMARY CARE FACILITIES - INFIRMARIES/
DISPENSARIES
Professional Health Care
RVS CODE DESCRIPTION Case Rate Fee Institution Fee
Page 2 of 22
ANNEX 6. LIST OF PROCEDURE CASE RATES FOR PRIMARY CARE FACILITIES - INFIRMARIES/
DISPENSARIES
Professional Health Care
RVS CODE DESCRIPTION Case Rate Fee Institution Fee
Page 3 of 22
ANNEX 6. LIST OF PROCEDURE CASE RATES FOR PRIMARY CARE FACILITIES - INFIRMARIES/
DISPENSARIES
Professional Health Care
RVS CODE DESCRIPTION Case Rate Fee Institution Fee
Page 4 of 22
ANNEX 6. LIST OF PROCEDURE CASE RATES FOR PRIMARY CARE FACILITIES - INFIRMARIES/
DISPENSARIES
Professional Health Care
RVS CODE DESCRIPTION Case Rate Fee Institution Fee
Page 5 of 22
ANNEX 6. LIST OF PROCEDURE CASE RATES FOR PRIMARY CARE FACILITIES - INFIRMARIES/
DISPENSARIES
Professional Health Care
RVS CODE DESCRIPTION Case Rate Fee Institution Fee
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ANNEX 6. LIST OF PROCEDURE CASE RATES FOR PRIMARY CARE FACILITIES - INFIRMARIES/
DISPENSARIES
Professional Health Care
RVS CODE DESCRIPTION Case Rate Fee Institution Fee
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ANNEX 6. LIST OF PROCEDURE CASE RATES FOR PRIMARY CARE FACILITIES - INFIRMARIES/
DISPENSARIES
Professional Health Care
RVS CODE DESCRIPTION Case Rate Fee Institution Fee
Page 8 of 22
ANNEX 6. LIST OF PROCEDURE CASE RATES FOR PRIMARY CARE FACILITIES - INFIRMARIES/
DISPENSARIES
Professional Health Care
RVS CODE DESCRIPTION Case Rate Fee Institution Fee
25065 Biopsy, soft tissue of forearm and/or wrist 2,453 353 2,100
Excision, tumor, forearm and/or wrist area;
25075 3,976 1,176 2,800
subcutaneous
Excision, tumor, forearm and/or wrist area; deep,
25076 5,614 1,764 3,850
subfascial or intramuscular
Excision, lesion of tendon sheath, forearm and/or
25110 5,614 1,764 3,850
wrist
25210 Carpectomy; one bone 4,152 1,352 2,800
26010 Drainage of finger abscess; simple 2,453 353 2,100
26011 Drainage of finger abscess; complicated (e.g., felon) 2,876 706 2,170
26020 Drainage of tendon sheath, one digit and/or palm 5,614 1,764 3,850
Tenolysis, simple, flexor tendon; palm or finger,
26440 5,614 1,764 3,850
single, each tendon
Tenolysis, extensor tendon, dorsum of hand or
26445 5,614 1,764 3,850
finger; each tendon
Arthroplasty, metacarpophalangeal joint; w/
26531 5,614 1,764 3,850
prosthetic implant, single, each
27040 Biopsy, soft tissue of pelvis and hip area 2,453 353 2,100
27047 Excision, tumor, pelvis and hip area; subcutaneous 3,976 1,176 2,800
27323 Biopsy, soft tissue of thigh or knee area 2,453 353 2,100
27327 Excision, tumor, thigh or knee area; subcutaneous 3,976 1,176 2,800
Excision, tumor, thigh or knee area; deep,
27328 5,614 1,764 3,850
subfascial, or intramuscular
Decompression fasciotomy, leg; anterior and/or
27600 5,614 1,764 3,850
lateral compartments only
Decompression fasciotomy, leg; posterior
27601 5,614 1,764 3,850
compartments(s) only
Incision and drainage, leg or ankle; deep abscess or
27603 2,876 706 2,170
hematoma
27604 Incision and drainage, leg or ankle; infected bursa 3,976 1,176 2,800
27613 Biopsy, soft tissue of leg or ankle area 2,453 353 2,100
27618 Excision, tumor, leg or ankle area; subcutaneous 3,976 1,176 2,800
Excision, tumor, leg or ankle area; deep, subfascial
27619 5,614 1,764 3,850
or intramuscular
Excision of lesion of tendon sheath or capsule (e.g.,
27630 3,976 1,176 2,800
cyst or ganglion), leg and/or ankle
27656 Repair, fascial defect of leg 3,976 1,176 2,800
28001 Incision and drainage, infected bursa, foot 3,976 1,176 2,800
28043 Excision, tumor, foot; subcutaneous 3,976 1,176 2,800
Excision, tumor, foot; deep, subfascial,
28045 5,614 1,764 3,850
intramuscular
Excision of interdigital (Morton) neuroma, single,
28080 3,976 1,176 2,800
each
Application of body cast, shoulder to hips; shoulder
29055 6,510 1,470 5,040
spica
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ANNEX 6. LIST OF PROCEDURE CASE RATES FOR PRIMARY CARE FACILITIES - INFIRMARIES/
DISPENSARIES
Professional Health Care
RVS CODE DESCRIPTION Case Rate Fee Institution Fee
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ANNEX 6. LIST OF PROCEDURE CASE RATES FOR PRIMARY CARE FACILITIES - INFIRMARIES/
DISPENSARIES
Professional Health Care
RVS CODE DESCRIPTION Case Rate Fee Institution Fee
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ANNEX 6. LIST OF PROCEDURE CASE RATES FOR PRIMARY CARE FACILITIES - INFIRMARIES/
DISPENSARIES
Professional Health Care
RVS CODE DESCRIPTION Case Rate Fee Institution Fee
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ANNEX 6. LIST OF PROCEDURE CASE RATES FOR PRIMARY CARE FACILITIES - INFIRMARIES/
DISPENSARIES
Professional Health Care
RVS CODE DESCRIPTION Case Rate Fee Institution Fee
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ANNEX 6. LIST OF PROCEDURE CASE RATES FOR PRIMARY CARE FACILITIES - INFIRMARIES/
DISPENSARIES
Professional Health Care
RVS CODE DESCRIPTION Case Rate Fee Institution Fee
Page 14 of 22
ANNEX 6. LIST OF PROCEDURE CASE RATES FOR PRIMARY CARE FACILITIES - INFIRMARIES/
DISPENSARIES
Professional Health Care
RVS CODE DESCRIPTION Case Rate Fee Institution Fee
Page 15 of 22
ANNEX 6. LIST OF PROCEDURE CASE RATES FOR PRIMARY CARE FACILITIES - INFIRMARIES/
DISPENSARIES
Professional Health Care
RVS CODE DESCRIPTION Case Rate Fee Institution Fee
56420 Incision and drainage of Bartholins gland abscess 6,510 1,470 5,040
56441 Lysis of labial adhesions 6,510 1,470 5,040
56501 Destruction of lesion(s), vulva; any method 6,510 1,470 5,040
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ANNEX 6. LIST OF PROCEDURE CASE RATES FOR PRIMARY CARE FACILITIES - INFIRMARIES/
DISPENSARIES
Professional Health Care
RVS CODE DESCRIPTION Case Rate Fee Institution Fee
Page 17 of 22
ANNEX 6. LIST OF PROCEDURE CASE RATES FOR PRIMARY CARE FACILITIES - INFIRMARIES/
DISPENSARIES
Professional Health Care
RVS CODE DESCRIPTION Case Rate Fee Institution Fee
64901 Nerve graft, each additional nerve; single strand 5,614 1,764 3,850
Nerve graft, each additional nerve; multiple strands
64902 5,614 1,764 3,850
(cable)
Removal of foreign body, external eye; conjunctival,
65205 2,548 588 1,960
superficial
Removal of foreign body, external eye;
65210 5,614 1,764 3,850
subconjunctival or scleral, with slit lamp
Removal of foreign body, external eye; cornea, with
65222 5,614 1,764 3,850
slit lamp
Repair of laceration; conjunctiva, w/ or w/o
65270 5,614 1,764 3,850
nonperforating laceration sclera, direct closure
Repair of laceration; conjunctiva, by mobilization
65273 5,614 1,764 3,850
and rearrangement
65410 Biopsy of cornea 5,614 1,764 3,850
Destruction of lesion of cornea by cryotherapy,
65450 5,614 1,764 3,850
photocoagulation or thermocauterization
Paracentesis of anterior chamber of eye; w/
65805 5,614 1,764 3,850
therapeutic release of aqueous
65930 Removal of blood clot, anterior segment eye 5,614 1,764 3,850
67700 Blepharotomy, drainage of abscess, eyelid 3,976 1,176 2,800
67710 Severing of tarsorrhaphy 3,976 1,176 2,800
67715 Canthotomy 3,976 1,176 2,800
67800 Excision of chalazion 3,976 1,176 2,800
67810 Biopsy of eyelid 3,976 1,176 2,800
Repair of trichiasis; by electroepilation,
67825 3,976 1,176 2,800
electrosurgery, cryotherapy or laser surgery
67830 Repair of trichiasis; incision of lid margin 2,548 588 1,960
Repair of trichiasis; incision of lid margin, with free
67835 6,510 1,470 5,040
mucous membrane graft
Excision of lesion of eyelid (except chalazion)
67840 3,892 882 3,010
without closure or with simple direct closure
Temporary closure of eyelids suture (e.g., frost
67875 3,976 1,176 2,800
suture)
Construction of intermargin adhesions, median
67880 3,976 1,176 2,800
tarsorrhaphy, or canthorrhaphy;
Construction of intermargin adhesions, median
67882 tarsorrhaphy, or canthorrhaphy; with transportation 5,614 1,764 3,850
of tarsal plate
67914 Repair of ectropion; suture 5,614 1,764 3,850
67915 Repair of ectropion; thermocauterization 5,614 1,764 3,850
67921 Repair of entropion; suture 3,976 1,176 2,800
67922 Repair of entropion; thermocauterization 3,976 1,176 2,800
68100 Biopsy of conjunctiva 3,976 1,176 2,800
68110 Excision of lesion, conjunctiva; up to 1 cm 5,614 1,764 3,850
68115 Excision of lesion, conjunctiva; over 1 cm 5,614 1,764 3,850
68130 Excision of lesion, conjunctiva; with adjacent sclera 5,614 1,764 3,850
68400 Incision, drainage of lacrimal gland 3,976 1,176 2,800
Incision, drainage of lacrimal sac
68420 3,976 1,176 2,800
(dacryocystostomy)
68440 Snip incision of lacrimal punctum 3,976 1,176 2,800
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ANNEX 6. LIST OF PROCEDURE CASE RATES FOR PRIMARY CARE FACILITIES - INFIRMARIES/
DISPENSARIES
Professional Health Care
RVS CODE DESCRIPTION Case Rate Fee Institution Fee
Page 19 of 22
ANNEX 6. LIST OF PROCEDURE CASE RATES FOR PRIMARY CARE FACILITIES - INFIRMARIES/
DISPENSARIES
Professional Health Care
RVS CODE DESCRIPTION Case Rate Fee Institution Fee
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ANNEX 6. LIST OF PROCEDURE CASE RATES FOR PRIMARY CARE FACILITIES - INFIRMARIES/
DISPENSARIES
Professional Health Care
RVS CODE DESCRIPTION Case Rate Fee Institution Fee
Page 21 of 22
ANNEX 6. LIST OF PROCEDURE CASE RATES FOR PRIMARY CARE FACILITIES - INFIRMARIES/
DISPENSARIES
Professional Health Care
RVS CODE DESCRIPTION Case Rate Fee Institution Fee
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